Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Saturday, November 21, 2009

Today's NYTimes has an article called Getting Mental Health Care When Money is Tight.Leslie Alderman writes:According to a recent survey by the federal Substance Abuse and Mental Health Services Administration (Samhsa, pronounced SAM-suh) , the leading reason that people with mental health issues don’t seek treatment is cost. They fear the fees.

The article goes on to list websites, support groups, self-help ideas (yes, exercise was in there!), pastoral counselors and an assortment of options for people who want help but are uncomfortable with the cost. The author even suggests:

If you have a good relationship with your primary care physician, you could see him or her. Your doctor may be able to refer you to a local mental health center for therapy, and maybe consider medication to help you out of your immediate funk. Doctors may also know of psychologists who see patients on a sliding fee scale.

Hmmm, sounds like psychiatrists aren't a very generous crew-- there's no mention of the idea that one of those might discount their fees.

In Maryland, there have traditionally been a few options:1) Community Mental Health Centers have treated uninsured, indigent patients, specifically those with major mental illnesses. These patients are deemed "gray zone" and have been cared for in the clinics....not sure that continues with all the governmental budget cuts. Often these patients end up being eligible for Medicaid, and sometimes SSDI (Social Security Disability) and eventually Medicare.2) Homeless patients (and homeless is defined pretty loosely, and not limited to 'street' people--) can be seen at Health Care for the Homeless-- they're sliding fee scale allows forvery low fees.3) The Pro Bono Counseling Project coordinates care for those with limited resources through a network of volunteers in the community. The list includes therapist of every ilk-- but I will say the social worker volunteers greatly outnumbers the psychiatrists.4) Teaching programs (and this was an option in the NYTimes article) offer treatments of all types--- including psychoanalytic training programs where discounted analysis is available.

Do you know of other resources? By all means, write in!

So my other thought was this. I think health insurance is a good thing, and actually, I hope some reasonable level of health care should be accessible to all, but given that it's not, have we become complacent in a way that's not helpful? The article starts out talking about a person with what may be a major depression and the person is afraid that the cost of treatment will add to the stress:

IMAGINE this situation. You fall into a deep malaise. Friends say you need help, but you don’t have insurance (or the insurance you do have has very limited mental health benefits), and you worry that extra bills will only add to your malaise. So you do nothing.

The article goes on to describe discount means of getting care, and you know I think these are all reasonable options. But we all know there are people who worry about money with a variety of thresholds-- one could worry that extra bills will add to the stress even if there's money in the bank. And no where does the article suggest that if there is some means of paying for care, that the cost of NOT getting treatment may well exceed the cost of getting care. Maybe the person above has a depressive episode-- maybe he'll go for an evaluation, a few weekly visits, then a year's worth of monthly visits, and get meds from Walmart or free doc samples. Let's pretend he responds well to the first medication, that he gets a lot out of a few therapy sessions, and ...hmm....maybe $600 later he feels a lot better. Let's say he doesn't spend that money and he's miserable. Let's say he loses his job, he loses opportunities...he lives life less fully.

I've watched people who pay $20K year for their child's kindergarten not be willing to go outside their HMO to get appropriate medical care for the same child.

I liked Alderman's article, she offers good suggestions. I guess I just wished that she'd made the suggestion that, if possible, psychiatric treatment might be worth paying for. I know I'm going to get comments from people who really do stretch to pay for their treatment. I'd love to hear from the folks who have a few resources but still elect not to get treatment they might like to have.

9
comments:

Community mental health centers don't do sliding scales anymore. My grey zone patients can't get medicaid or medical assistance for months and usually don't qualify for disability. If they don't live near Health Care for the Homeless, don't have a relative who will pay for their meds or a job to pay for their own, they're SOL (sadly out of luck). They have to wait to get arrested again, in which case they'll get screened for physical and mental disorders, get seen by a psychiatrist and/or psychology, and get meds----free of charge.

Hummus stays good for up to six months. Sabra is the best, except for homemade (at my place, anyway).

First, some of us have kept our fees low rather than artificially inflating them to get the most out of insurance or Medicare.

Second, psychiatrists are not the bailout.

Finally: How many of those folks who can't afford to pay a doctor seem to always find a way to pay for cigarettes?

We need to remember that psychiatry is already at the bottom of the heap as far as income is concerned which is one reason many of us are no longer providing psychotherapy. If we reduce our incomes further fewer good people will choose psychiatry.

If everyone is entitled to medical care, that should not apply to psychoanalysis or other treatment whose primary goal is to "understand" oneself. We will need to do triage and provide care first to people with schizophrenia and other serious mental disorders. IF we adopt a position that all are entitled, I am leaning toward a single payer system, but there will be rationing or we won't be able to afford to care for everyone. At least the worried well will have a little less to worry about.

Of course I believe we physicians, with all our regulation, are probably almost all daily felons. If they convict us all and put in prison at least we will get free health care. But who will be left to provide it?

Very good point about the cost of depression. I figure the period where I was most ill cost me at least $50,000 in lost tuition, lost scholarships, and lost rent. And that doesn't count the lost income from entering the workforce years later than I otherwise would have. I now spend close to $200 an hour each week for therapy; it's a bargain if it keeps me from having to take another leave due to mental illness.

I've been in and out of psychiatric care for the last six months and I can't believe 1) how expensive it is; and 2) how hard it is to find out how expensive it is before you use the services. I was in a couple of inpatient facilities and I get bills almost weekly from doctors I've never heard of who as near as I can tell just popped their heads in the door for five minutes a couple of times to see how I was doing. The hospitals themselves were a thousand dollars a day and the labs, consults, and other services are charged separately from that. The psychiatrist I see costs $400 per hour. I have good insurance so I just toss these bills on the pile, but I can certainly understand why people would be reluctant to get involved in such an expensive system. Every time someone suggested some therapy for me and I asked how much it would cost, I was just told "don't worry about it." Well, some people do need to worry about cost. Even worse was when I asked if my insurance would cover it and I was told "don't worry about it." How can people not worry about things like this? My mental health care in the last six months would have cost an uninsured person almost $80,000.

Moviedoc: It's not just cigarettes. I have stories. I can't tell them.

Merope3: I wasn't talking about inpatient care--incredibly expensive and I agree that the bills are not decipherable. But one more reason to make paying for outpatient treatment a priority: much cheaper if one can avoid needing hospital care.

merope3: Thanks for the numbers. Now if we divide that $80k by 6 we get over $13,000 per month. If we figure $500 per month premium it will take ~27 subscribers with zero claims just to cover what was billed. And that doesn't even include as much as 40% overhead for the insurance company. I read the other day that 45,000 people died because they couldn't see a doc at all. We can't afford to pay psychiatrists $400 "per hour" (usually this means per session which may be only 45-50 minutes) for psychotherapy when non-physicians do it very well for much less. And you say someone with no insurance would pay $80,000. It's very likely the hospital and the psychiatrist have agreed to pay lower fees because they are in bed with an insurer.

Dinah: Wish I could hear those stories, but there are interesting things about cigarettes: what if you proposed to lower your fee by what the patient spends on them and/or alcohol, both of which are hurting them? If it would just get them to quit smoking it might save a life. And last time I heard, smoking alone cost $40 billion a year just in the US.

In a perfect world, we would lose the "mental" in mental illness. Truly. Major depression, schizophrenia, anxiety disorders...these are illnesses that should be covered by insurance, just like cancer and diabetes.

I'm managing my depression through diet, exercise, and antidepressants prescribed by my GP. Therapy was also helpful for me and I paid $400 / month out-of-pocket for weekly sessions until my husband lost his job. I'm taking a therapy break until we get back on firmer financial footing.

The self-insight I gained last year in therapy has helped immensely, and instead of beating myself up constantly, I'm working to be kind to myself and care for myself. (Things like eating well and getting enough sleep.)

Without the year of therapy, I don't think the meds would be as effective -- especially right now when we're under so much stress. (We're both currently self-employed.)

Is everyone *entitled* to this kind of awareness? Maybe not. My husband and I work hard, pay our bills on time, and don't smoke or drink. We have three kids and while our income has usually been high, we're getting by right now with much less. I'm thankful to be in the position we're in -- we can pay for necessities, which is much more than a lot of families can say right now. I will say, it's really frustrating to pay through the nose for health insurance and not have it cover health-related expenses like therapy. (We pay $350 / mo. for my husband and three kids on a private insurance plan, and I pay $389 / mo. just for me through ichip (because of my pre-existing, I couldn't get health insurance anywhere else). And yet, thank goodness we're able to pay these premiums. One of my boys broke his arm this summer and needed surgery and extensive PT. I shudder to think how much we would owe without insurance.

I plan to go back to therapy next year because I think for me it's an important part of taking care of myself. Just stopping in every other week and touching bases with someone really does give me a lot of perspective on myself and my actions, and helps me take better care of myself and the people around me.

I suppose that qualifies me as the "worried well," and yet if I drop it all, suddenly I could become very sick again.

I will say that after going through all I have gone through, I see therapy and mental health expenses as VERY worthwhile. I don't say, "Wow, I spent $5000 on therapy and meds last year"...I say, "THANK GOD!" Truly, that $5000 was the best money I spent last year. It gave me my life back, and has given my children their mother back -- the healthy mom they deserve to have!

We live in Maryland and have HMO coverage. From hard experience I can say that it is worth it to pay someone outside the HMO.

There can be a lot of value to setting yourself or a child up with a private therapist where you can get an appointment at the same time every week or even on a predictable basis. If you work the value of a thearpist who is within striking distance of your lunch hour is very helpful and probably worth the money.

If you need meds you can take the recommendation back to the HMO and get those there since oftentimes they come with prescription coverage.

That said I haven't had any REALLY serious major long-term issues so I don't know what a person would do then.

With teen aged children it's worth weighing the cost of some appointments against what a lawyer is going to eventually cost if your child is headed in a direction that looks like they'll have interaction with the law.

Therapy is eligible for reimbursement with a flexible spending plan so if you have that available you can set some money aside and go that way.

Prisons are where many with severe mental illnesses are living today. Because of my state's budget crisis, thousands of inmates will now be getting out of prison early, and alternatives to incarceration are being more aggressively pursued for others.

The community MH centers in my state were already overwhelmed with indigent patients before the decision to release more offenders to the community was made.

I can give them the name, addres, and phone number of the CMH center for the county they will be living in (when they get released),but whether there will actually be any access to care for them is the problem.

As a psychiatrist in corrections, I often feel helpless when I am able to help patients gain stability, realizing that it all may fall apart as soon as they get out.

It's going to get worse now that more are being released to the streets. As Clink Shrink points out, many will need to go back to prison in order to gain access to MH treatment again. Very sad, but true.

(I'd like to say something positive, but the reality here is not so rosy...)